Healthcare Provider Details

I. General information

NPI: 1053002923
Provider Name (Legal Business Name): JEROME BATES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 BELLEVUE ST SE
WASHINGTON DC
20032-6030
US

IV. Provider business mailing address

171 SOMERVELLE ST APT 410
ALEXANDRIA VA
22304-8651
US

V. Phone/Fax

Practice location:
  • Phone: 202-562-4939
  • Fax:
Mailing address:
  • Phone: 301-385-3071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: